Provider Demographics
NPI:1629472220
Name:LAUCK, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LAUCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-238-6585
Mailing Address - Fax:605-328-6512
Practice Address - Street 1:1621 S MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1743
Practice Address - Country:US
Practice Address - Phone:605-328-4700
Practice Address - Fax:605-328-4702
Is Sole Proprietor?:No
Enumeration Date:2014-10-10
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLPC-MH2269101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health